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rfi g. f understand I may obtain more information regarding my obligations as an "employe/'from the lnternal Revenue Ser- <br />vibe, the United States Small Business Administration, the California Degartme?t of Beneflt Payments, and the California Divi- <br />sion of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1 -800- <br />321-CSLB (2752) or www.cslb.ca.qov for more information about licensed contractors. <br />lh-f o I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the <br />party le <br />dress: <br />gally 9rd\o Nfina al resp onsible proposed construction activity at the following ad- <br />3-r',. I agree that. as the party legally and financially responsible for this proposed construction activrty, I wall abide by all <br />applicable laws and requirements that govern Owner-Builders as well as employers. <br />!-a, I agree to notify the issuer of this form immediately of any addations, deletions, or changes to any of the anformation I <br />have provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not have a <br />license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of <br />a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for you to understand <br />that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held <br />liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will be responsible for verifying <br />whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. <br />tion, or other veritication acceptable to the aqency is required to be presented when the permit is issued to verify the <br />W 0 elotl t-rSignature of Property Owner Date <br />-Juxa p,o <br />7/1.,/ <br />Print name of Owner <br />AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF <br />\ <br />Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize <br />the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder <br />Permit for my project. <br />Scope of Construction Project (or Description of Work) <br />0{Ft.'ln <br />Address of Authorized Agent t\{*t 0,otc}- friud . wosl nunster Aktt6gz <br />( <br />Phone Number of Authorized Agent O 7-2. <br />I declare under penalty of per.lury that I am the property owner for the address listed above and I personally filled out the above <br />information and certify its accuracy <br />Property Owneis Signature Date 7() <br />Print Name of Owner '\tl,'te ft o <br />Note: A copy of the ownet's dliver's license, form nota zation, or other verification acceptable to the agency is re- <br />quired to be presented when the permit is issued to verify the property owner's signature. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and returned <br />to the agency responsible for issuing the permit. /Vofe: A copv of the oropertv ownet's driver's license, form notariza- <br />propeftv owner's si(lnatu re. <br />Project Location or Address: <br />Name of Authorized Agent: